Maternal-Fetal Medicine Practice Questions

Q: A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia? 1. Headache 2. Blurred vision 3. Persistent pedal oedema 4. Epigastric pain

1 and 2 only. ***1 and 2 only*** - **Headache** (severe, persistent, frontal or occipital) and **blurred vision** (scotomas, photophobia, or visual field defects) are the classic **neurological symptoms** indicating cerebral irritation and vasospasm that directly precede eclamptic seizures. - These symptoms reflect **imminent CNS involvement** and are the strongest predictors of impending seizure, requiring urgent intervention (magnesium sulfate prophylaxis, delivery planning). - While other symptoms indicate severe pre-eclampsia, these neurological signs specifically herald **imminent eclampsia**. *2 and 4 only* - **Blurred vision** is indeed a key warning sign, and **epigastric pain** (right upper quadrant pain) is an important symptom of severe pre-eclampsia indicating hepatic capsule distension or subcapsular hematoma. - However, this option misses **headache**, which is one of the most critical neurological warning signs of imminent seizure. Epigastric pain indicates hepatic involvement (severe disease) but is not as directly predictive of immediate seizure onset as the combination of headache and visual disturbances. *1,2,3,4* - While headache, blurred vision, and epigastric pain are all features of severe pre-eclampsia, **persistent pedal edema** is extremely common in normal pregnancy and pre-eclampsia (present in >80% of cases) and is **not a specific indicator of imminent eclampsia**. - Generalized edema alone does not indicate imminent seizure risk and is too non-specific to be grouped with the acute neurological warning signs. *1,2,3* - **Headache** and **blurred vision** are the correct neurological indicators of imminent eclampsia. - However, **persistent pedal edema** is very common in pre-eclampsia and not specific for imminent eclamptic seizure risk. It does not have the same predictive value as severe headache or acute visual disturbances for identifying patients at immediate risk of convulsion.

Q: A 29-year-old woman tests positive for HIV during pregnancy screening. She is concerned about transmission to her baby. Which of the following interventions most significantly reduces the risk of vertical transmission?

Antiretroviral therapy during pregnancy and labor. ***Antiretroviral therapy during pregnancy and labor*** - **Antiretroviral therapy (ART)** significantly reduces the **viral load** in the mother, thereby minimizing the risk of HIV transmission to the fetus during pregnancy and childbirth. - When combined with other strategies like **cesarean section** and **avoidance of breastfeeding** in developed countries, ART can reduce vertical transmission rates to less than 1%. *Avoiding breastfeeding only* - While **avoiding breastfeeding** is a crucial intervention, especially in settings where safe alternatives are available, it addresses only one mode of transmission (postnatal). - It does not prevent **in-utero** or **intrapartum transmission**, which are primary routes of vertical transmission if the viral load is high. *Cesarean delivery only* - **Cesarean delivery** can reduce the risk of transmission by avoiding exposure to maternal blood and secretions during vaginal delivery. - However, it is most effective when the maternal **viral load is high** and is often combined with ART for maximum efficacy; it's less effective without ART. *Maternal immunization* - **Maternal immunization** involves administering vaccines to the mother to protect against specific infections, primarily bacterial or viral diseases like influenza or tetanus. - It has **no direct impact** on the risk of HIV transmission, as there is currently no vaccine available for HIV.

Q: Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?

Elective cesarean at 40 weeks. ***Elective cesarean at 40 weeks*** - This is **NOT recommended** as stated because: - When elective cesarean section is indicated (viral load >1000 copies/mL), it should be performed at **38 weeks gestation**, NOT 40 weeks - At 40 weeks, there's increased risk of spontaneous labor and membrane rupture, which defeats the purpose of elective cesarean - With adequate viral suppression (<1000 copies/mL or undetectable), **vaginal delivery is safe** and cesarean is not routinely recommended - The decision for cesarean is based on **viral load**, not simply gestational age *Avoidance of breastfeeding* - **Breastfeeding** is a known route of vertical HIV transmission due to the presence of the virus in breast milk - In developed countries where safe alternatives are available, **formula feeding** is recommended to completely eliminate this risk - This IS a recommended prevention strategy *Intrapartum zidovudine* - **Intravenous zidovudine (AZT)** administered during labor effectively reduces HIV transmission from mother to child - This is a crucial component of the prevention protocol, especially for mothers with detectable viral loads or those who have not received full antiretroviral therapy - This IS a recommended prevention strategy *Antiretroviral therapy during pregnancy* - **Antiretroviral therapy (ART)** taken throughout pregnancy significantly lowers the maternal viral load, which is the most critical factor in preventing vertical transmission - Suppressing the viral load to **undetectable levels** before delivery is the primary goal and most effective strategy - This IS a recommended prevention strategy

Q: A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

MgSO4 + Labetalol. ***MgSO4 + Labetalol*** - The patient presents with **eclampsia**, characterized by convulsions and severe hypertension (BP 170/100 mmHg) during pregnancy. Magnesium sulfate (**MgSO4**) is the **first-line treatment for preventing and managing eclamptic seizures**. - **Labetalol** is an appropriate antihypertensive for **severe hypertension in pregnancy** (BP ≥160/110 mmHg) and must be used concurrently with MgSO4 to control the high blood pressure and prevent maternal complications like stroke or placental abruption. - Both medications are required for comprehensive management of eclampsia with severe hypertension. *Clonidine* - **Clonidine** is an alpha-2 adrenergic agonist used to treat hypertension but is **not the first-line antihypertensive choice in acute eclampsia** due to potential sedative effects and slower onset compared to other agents like Labetalol, Hydralazine, or Nifedipine. - While it can lower blood pressure, it **does not address the seizure risk** in eclampsia. *Only Labetalol* - While **Labetalol** is crucial for managing severe hypertension, treating eclampsia requires both seizure control and blood pressure management. Administering only Labetalol would **fail to prevent recurrent seizures**, which is the primary life-threatening concern. - It would adequately lower blood pressure but **does not address the underlying seizure pathology** of eclampsia. *Only MgSO4* - **MgSO4** is essential for seizure prophylaxis and treatment in eclampsia. However, in this patient with a blood pressure of **170/100 mmHg (severe hypertension)**, **MgSO4 alone would not adequately control the severe hypertension**, which poses risks of maternal complications like stroke, intracerebral hemorrhage, or placental abruption. - While it prevents seizures effectively, it **does not sufficiently manage severe maternal hypertension**, requiring an additional antihypertensive agent like Labetalol.

Q: A G4P2 lady presented with history of two abortions at 16 weeks and 20 weeks POG. Which of the following could be the most likely reason for these abortions?

Cervical incompetence. ***Cervical incompetence*** - **Recurrent second-trimester pregnancy losses** (16 and 20 weeks) with a history of two previous abortions are highly suggestive of cervical incompetence, where the cervix dilates prematurely. - This condition is characterized by painless, progressive cervical dilation leading to **fetal expulsion** without contractions, which aligns with the presentation of repeated mid-trimester abortions. *Thyroid abnormality* - While **untreated hypothyroidism** or **hyperthyroidism** can increase the risk of miscarriage, these typically lead to **earlier first-trimester losses** or other obstetric complications, not recurrent mid-trimester abortions. - Abortion due to thyroid dysfunction is often associated with other signs and symptoms of thyroid disease, which are not mentioned. *Chromosomal abnormality* - **Chromosomal abnormalities** are the most common cause of **first-trimester miscarriages**, accounting for about 50% of them. - While they can cause later losses, recurrent mid-trimester abortions are less commonly attributed solely to chromosomal issues, especially in the absence of other malformations. *Placenta previa* - **Placenta previa** is a condition where the placenta partially or totally covers the cervix, causing painless vaginal bleeding in the **late second or third trimester**. - It increases the risk of preterm birth but is not a direct cause of recurrent fetal loss at 16 and 20 weeks gestation in the manner described.

Q: Which of the following can be a cause of Oligohydramnios?

Renal agenesis. ***Renal agenesis*** - **Fetal urine production** is the primary source of **amniotic fluid** in the latter half of pregnancy, so **bilateral renal agenesis** prevents this production. - Oligohydramnios due to renal agenesis is often associated with **Potter sequence**, characterized by facial anomalies, limb deformities, and pulmonary hypoplasia due to prolonged severe oligohydramnios. *Macrosomia* - **Macrosomia** (large baby) is not a cause of oligohydramnios; a larger fetus does not directly reduce amniotic fluid volume. - In fact, conditions like **gestational diabetes** which can cause macrosomia, are often associated with **polyhydramnios** (excess amniotic fluid) due to increased fetal urination. *Multiparity* - **Multiparity** (having had multiple previous pregnancies) is not directly associated with oligohydramnios. - While it can be a risk factor for certain pregnancy complications, it does not physiologically lead to reduced amniotic fluid. *Twins* - A multifetal pregnancy, such as **twins**, can sometimes be associated with complications like **twin-to-twin transfusion syndrome**, where one twin might develop oligohydramnios and the other polyhydramnios. - However, the presence of twins itself does not intrinsically cause oligohydramnios; it is a potential complication of specific twin types or their pathologies rather than a direct cause.

Q: In a patient with ectopic tubal pregnancy which is the earliest to rupture?

Isthmus. ***Isthmus*** - The **isthmus** is the **narrowest part** of the fallopian tube with the **least distensibility** and thin muscular wall. - Due to its limited capacity to accommodate the growing pregnancy, ectopic pregnancies in the isthmus rupture **earliest**, typically between **6-8 weeks of gestation**. - Rupture is often severe due to the narrow lumen and limited ability to expand. *Ampulla* - The **ampulla** is the most common site for ectopic pregnancies (approximately **70%** of cases). - It is wider and more distensible than the isthmus, allowing the pregnancy to grow for a longer period. - Rupture typically occurs **later**, between **8-12 weeks of gestation**. *Interstitial* - The **interstitial** (or cornual) portion is located within the **uterine wall**, surrounded by myometrium and rich vascular supply. - This location allows significant distensibility, so rupture occurs **latest** among tubal sites, typically at **12-16 weeks of gestation**. - When rupture occurs, it is **most catastrophic** with severe hemorrhage and highest risk of **maternal morbidity and mortality** due to the vascular supply. *Infundibulum* - Ectopic pregnancies in the **infundibulum** or fimbrial end are very rare. - Due to the wide opening, these pregnancies typically present as **tubal abortion** through the fimbria rather than rupture. - The area is less muscular, making contained rupture uncommon.

Q: Which of the following is consistent with a decision to perform a cerclage?

Cervix dilated to 3 cm. ***Cervix dilated to 3 cm*** - In the context of **mid-trimester cervical dilation** (before 24 weeks) without contractions or bleeding, this represents **cervical insufficiency** - a potential indication for **emergency (rescue) cerclage**. - While 3 cm dilation is at the **upper limit** and somewhat controversial, emergency cerclage may still be considered if membranes are intact, there are no contractions, and gestational age is <24 weeks. - This is the **only option** that represents a clinical scenario where cerclage might be performed, as the other three options are **absolute contraindications**. - Note: Most clinicians prefer cervical dilation **<2 cm** for rescue cerclage, but individual cases at 2-3 cm may be considered based on clinical judgment. *Gestation of 26 weeks* - Cerclage is typically placed between **12-14 weeks** (prophylactic) or up to **23-24 weeks** (emergency). - At **26 weeks**, cerclage is **contraindicated** - the risks (membrane rupture, infection, preterm labor) outweigh benefits at this advanced gestation. - This is an **absolute contraindication** regardless of cervical findings. *Uterine bleeding* - **Active uterine bleeding** is an **absolute contraindication** to cerclage placement. - Bleeding increases risks of **infection, membrane rupture, and preterm labor**. - Must rule out **placental abruption, placenta previa**, or other complications before considering any cervical intervention. *Uterine contractions* - **Active uterine contractions** are an **absolute contraindication** for cerclage. - Placing cerclage during contractions can precipitate **preterm labor and delivery**. - Contractions indicate the cervix may be responding to labor stimuli, making cerclage ineffective and potentially harmful.

Question 1

A pregnant woman at 36 weeks gestation is found to have high blood pressure recording and a urine protein of 3+. Concomitant presence of which of the following symptoms would make you suspect imminent eclampsia?

1. Headache
2. Blurred vision
3. Persistent pedal oedema
4. Epigastric pain

Accepted Answer

1 and 2 only

Answer

1,2,3,4

Answer

2 and 4 only

Answer

1,2,3

Question 2

A 29-year-old woman tests positive for HIV during pregnancy screening. She is concerned about transmission to her baby. Which of the following interventions most significantly reduces the risk of vertical transmission?

Accepted Answer

Antiretroviral therapy during pregnancy and labor

Answer

Avoiding breastfeeding only

Answer

Cesarean delivery only

Answer

Maternal immunization

Question 3

Which of the following is NOT a recommended prevention strategy for vertical transmission of HIV?

Accepted Answer

Elective cesarean at 40 weeks

Answer

Avoidance of breastfeeding

Answer

Intrapartum zidovudine

Answer

Antiretroviral therapy during pregnancy

Question 4

A 32 year old pregnant woman presents with 36 week pregnancy with complaints of pain abdomen and decreased fetal movements. Upon examination PR= 96/min, BP = 156/100 mm Hg, FHR = 128 bpm. On per-vaginum examination there is altered blood seen and cervix is soft 1 cm dilated. What is the preferred management?

Accepted Answer

Perform cesarean section

Answer

Observation and monitoring

Answer

Initiate labor induction

Answer

Administer medications to delay labor

Question 5

A 26-week pregnant female presents with hypertension for the first time. There is no proteinuria. What is the most likely diagnosis?

Accepted Answer

Hypertension diagnosed after 20 weeks of gestation without proteinuria

Answer

Hypertension diagnosed before 20 weeks of gestation

Answer

Hypertension with proteinuria or end-organ damage

Answer

Hypertension with seizures

Question 6

A 35-year-old woman at 36 weeks of gestation presents with a history of 5 convulsions at home. Her BP is 170/100 mmHg. The diagnosis made by the doctor is eclampsia. What is the next management?

Accepted Answer

MgSO4 + Labetalol

Answer

Clonidine

Answer

Only Labetalol

Answer

Only MgSO4

Question 7

A G4P2 lady presented with history of two abortions at 16 weeks and 20 weeks POG. Which of the following could be the most likely reason for these abortions?

Accepted Answer

Cervical incompetence

Answer

Thyroid abnormality

Answer

Chromosomal abnormality

Answer

Placenta previa

Question 8

Which of the following can be a cause of Oligohydramnios?

Accepted Answer

Renal agenesis

Answer

Macrosomia

Answer

Multiparity

Answer

Twins

Question 9

In a patient with ectopic tubal pregnancy which is the earliest to rupture?

Accepted Answer

Isthmus

Answer

Infundibulum

Answer

Ampulla

Answer

Interstitial

Question 10

Which of the following is consistent with a decision to perform a cerclage?

Accepted Answer

Cervix dilated to 3 cm

Answer

Gestation of 26 weeks

Answer

Uterine bleeding

Answer

Uterine contractions

Maternal-Fetal Medicine — MCQs

Maternal-Fetal Medicine — MCQs

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